Hysterectomy and Stress-Urinary-Incontinence Surgery

Paper Info
Page count 33
Word count 9038
Read time 38 min
Topic Health
Type Proposal
Language 🇺🇸 US

Hysterectomy has its origin in pre-historic times, with the first operation performed as early as 120 AD by Soranus in Greece. One historian claimed that Themison of Athens performed hysterectomy 50 years before Christ (Lameras, 1975 as cited in Sutton, 1997). Alsaharavius, a physician in the 11th century, made a commentary about a surgical excision of the uterus. Vaginal hysterectomies had been performed in the middle ages, as revealed by some medical writings (Sutton, 1997).

In 1809, Ephraim McDowell performed the first abdominal hysterectomy on Jane Todd Crawford, who had a massive ovarian cyst weighing 10.2 kilograms. It took McDowell 25 minutes to remove the left tube and the ovary, while outside his house townsfolk were building a gallows for him in case the patient would die. Five days later, Jane Todd was well and up in McDowell’s house and after 20 days, she went home to Greensburgh, Kentucky till she lived in her ripe old age. At that time, surgeons operated without anesthesia, antisepsis or antibiotics, and the patient was allowed to recite the psalms to slightly ease the pain. McDowell performed 13 hysterectomies in the course of his practice, with only one death. It was an extraordinary feat considering that sepsis and peritonitis were complications after laparotomy (Sutton, 1997).

Charles Clay (as cited in Sutton, 1997), who coined the word “ovariotomy” performed 395 hysterectomies in Europe, with only 25 deaths. On September 13, 1842, he removed a 17-pound, 5 ounce ovarian tumor, with the patient having a brandy and milk for analgesia. When anesthesia was discovered, Clay did not want to apply it for his patients as he considered it a distraction. He reasoned out that patients who had the courage to undergo surgery without anesthesia were imbued with a strong will to live. On January the 3rd, 1863, Clay (1863) performed the first successful hysterectomy with oophorectomy and salpingectomy (Sutton, 1997).

In 1853, Ellis Burnham successfully performed a subtotal hysterectomy and the patient survived. Another surgeon named Kimball (1855 as cited in Sutton, 1997) performed a deliberate but successful hysterectomy on a fibroid tumor. Chloroform as a form of anesthesia was introduced on the patient. Before this time, surgeons used opiates, which contained hyoscyamus and mandragora, mixed with alcohol to desensitize patients undergoing surgery. The nitrous oxide gas was introduced which could induce amusement and euphoria and reduce sensitivity to pain. In 1831, a combination of ether, nitrous oxide and chloroform was later used as anesthesia. Dentists used ether as dental anesthesia and it was Oliver Wendell Holmes who first coined the word anesthesia (Sutton, 1997).

Many women undergo hysterectomy for noncancerous illnesses and as a preemptive measure for ovarian cancer. Gynecological problems and cancer are the primary causes of hysterectomy. Hysterectomy cases in the United States are result of localized sickness, which means the sickness does not spread to the uterus, and removal of the uterus is not necessary (Sparić, Hudelist, Berisava, Gudović & Buzadzić, 2011).

About a quarter of women in the United States may have undergone hysterectomy when they have reached 60 years old. In the United Kingdom, the ratio is one to five women (Marks & Shinberg, 2007). More than 90 percent of those surgeries were performed for benign tumors and symptoms for uterine fibroids, vaginal bleeding, and others which are non-life threatening (Wilcox et al., 2005). Gupta and Manyonda (2014) indicated that 40 percent of all women worldwide will have a hysterectomy when they reach 64 years old, with the primary objective of relieving pain and enhancing quality of life. With the introduction of alternative treatment, hysterectomy has become less prevalent in most countries (Forsgren & Altman, 2013).

There are still doubts surrounding hysterectomy and why women should undergo hysterectomy. These questions are: Can hysterectomy provide the essential treatment for diseases in women’s reproductive organs? Should other less invasive treatment be considered first before a woman should undergo hysterectomy? How informed are women of the legal aspects of hysterectomy, particularly the subject of informed consent?

Hysterectomy is one of the most frequently used operative techniques but is significantly decreasing because there are alternative options and patients have reported some complications after hysterectomy (Darwish, Atlantis, & Mohamed-Taysir, 2014). Hysterectomy is more prevalent in the United States than in other Western countries, and studies have shown that people of color are more susceptible than Whites (Farquhar & Steiner, 2002). A longitudinal study found that more women who belonged to lower socio-economic class had undergone hysterectomy than those of the higher socio-economic status (Materia et al., 2005). Knowledge about, and access to, other treatment may not be available in specific areas, which is one of the reasons why those who are of the lower socioeconomic status mostly undergo hysterectomy (Bower, Schreiner, Sternfeld, & Lewis, 2009).

In the Mississippi Delta Region, poverty and unemployment were some of the social problems women faced. There were insufficiencies in education, poor nutrition, and not enough health care. These factors could have resulted in lack of valuable information for women who might have undergone hysterectomies, and there is also “underutilization of cancer screening leading to higher incidence of late-stage cancer, health care costs, and death rates” (Hall, Jamison, Coughlin, & Uhler, 2004, p. 375).

Every year, approximately 600,000 American women undergo hysterectomy for non-cancerous causes (Harvard Women’s Health Watch, 2009; Perera et al., 2013). Hysterectomy cases in the United States are believed the highest on record among developed countries (Brett & Higgins, 2007). In a report by the Centers for Disease Control and Prevention, there were 5.4 hysterectomies for every 1,000 women annually during the period 2000 to 2004 (Schollmeyer et al., 2014). However, hysterectomy rate is decreasing in the Scandinavian countries and in the United Kingdom (Schollmeyer et al., 2014).

Ovarian and uterine cancers are primary causes for hysterectomy (Singh, Ryerson, Wu, &Kaur, 2014).In a study on cervical cancer, researchers found that hysterectomy did not reduce the survival rate but provided comfort in the pelvic region (Keys et al., 1999). Moreover, some doctors performed hysterectomy on complaints of endometriosis, which can be treated with analgesic therapies and other non-invasive methods (Graaff et al., 2013).

A study on endometriosis and its effects on the quality of life revealed that this sickness impacted on “education, work and social wellbeing experienced in the period between the women’s first symptoms up to the time of the study” (Graaff et al., 2013, p. 2682). The effect of endometriosis on work was more pronounced with 51 percent of the participants saying that endometriosis significantly affected their work life. Endometriosis also affected the women’s relationships with their husbands, with some participants saying that their sickness caused divorce. The data collected in the study confirmed the negative effects of endometriosis on “education, work and social wellbeing as has been addressed in previous studies” (Graaff et al., 2013, p. 2682). Fibroids and uterine myomas or leiomyomas are some of the common causes of menstrual bleeding. Approximately 30 percent of hysterectomies are caused by fibroids. Myomectomy is an alternative to hysterectomy in removing fibroids, but it requires a longer recovery period (Harvard Women’s Health Watch, 1998).

Meaning and Causes

Hysterectomy is a surgical method to treat gynecological problems with the aim of removing a part or the uterus. After hysterectomy, a woman experiences a menopausal period and will be unable to become pregnant (Parkinson-Hardman, 2007). Uterus removal eliminates uterine cancer and oophorectomy (removal of the ovary) eradicates the risk of ovarian cancer (Wong et al., 2011). Yeh et al. (2013) indicated that bilateral salpingo-oophorectomy (BSO) can reduce the risk of ovarian cancer − the reason why it is performed bilaterally with hysterectomies. While ovarian cancer can be avoided, oophorectomy increases risks of heart disease and lung cancer (Harvard Women’s Health Watch, 2009). Cardiovascular risks may be higher because production of endogenous sex hormone is reduced. Yeh et al. (2013, p. 2620) found that “hysterectomy for benign disease could increase vascular risks in women.” A previous cohort study conducted by Ingelsson, Lundholm, Johansson, and Altman (2011 as cited in Yeh et al., 2013) supported evidence on the relation of hysterectomy and cardiovascular disease in women who were less than 45 years of age during operation.

Relation of HRT and CHD

There have been studies saying that hormone replacement therapy (HRT), which is prescribed for women who have undergone hysterectomy, causes coronary heart disease (CHD). However, there were studies reporting that HRT users did not have cardiovascular risks, while some studies showed that the effects of HRT were not clear and “over-estimated” (Vandenbroucke, 1995; Matthews, Kuller, & Wing, 1996; PosthumaWestendorp, & Vandenbrouche, 1994 as cited in Lambert, Straton, Knuiman, & Bartholomew, 2003, p. 294). Women with the uterus intact take prescribed estrogen and progestin as protection from cancer occurrence. HRT, which has a dose of progestin, can ease estrogen in controlling CHD, although there has been a reported little increase in CHD in women who take the combined dosage. The study of Lambert et al. (2003) provided inconclusive evidence that HRT caused CHD but the findings also stated that HRT was associated with hysterectomy. Women who use HRT have lower levels of systolic blood pressure and low cholesterol (Prior, Stanley, Smith, & Read, 1992).

Techniques and Types of Hysterectomies

Techniques in hysterectomy include open surgery performed through the vagina or a method using laparoscopy, and the most modern which is robot-assisted operation (Tapper et al., 2014). Laparoscopic hysterectomy (LH) is usually applied in benign and malignant tumors. Vaginal hysterectomy is used in many cases while LH is usually performed in cancer cases (Tapper et al., 2014). LH can be performed vaginally accompanied by laparoscopic procedures or where there is no vaginal component. The American Gynecologic Laparoscopists issued a statement in 2010 that hysterectomies for benign cases should use vaginal or laparoscopic procedures because of the benefits on women (Gupta &Manyonda, 2014). These benefits include lower costs effective, shorter hospital stay and quick recovery (Padial et al., 1992 and Liu, 1992 as cited in Weber & Lee, 1996). However, in a later study in Ohio by the same authors, they found that this method was associated with higher charges than the other two techniques of hysterectomy. In this same study, Weber and Lee (1996) found that the rate of hysterectomy in the state decreased between 1988 and 1994 due to the introduction and constant use of laparoscopically-assisted vaginal hysterectomy.

Complete hysterectomy aims for the uterus along with the cervix while partial hysterectomy does not aim for uterus removal. Supracervical hysterectomy is the removal of the body of the uterus and a portion of the cervix is sewn up to close. Supracervical is performed when complications during operation necessitates completing the required surgery as early as possible. However, supracervical hysterectomy should be planned for patients “with higher than average risks for perioperative complications” (Jones, Shackelford, & Brame, 1999, p. 514).

Vaginal hysterectomy is surgery performed through the vagina wherein the surgeon conducts operation on the vaginal wall to be able to see the ligaments and tissues of the uterus, ovaries, and fallopian tubes (Sheth, 2013). These organs can be removed through the vagina (Thakar, Ayers, Clarkson, Stanton, &Manyonda, 2002). Findings in randomized trials have shown that “vaginal hysterectomy is the most beneficial hysterectomy procedure for women, as well as being the most cost-effective” (Benassi et al., 2003; Ayoubi et al., 2003; Ribeiro et al., 2003 as cited in Boosz et al., 2011, p. 269).

In total hysterectomy, the portion called the “top” of the vagina is closed, creating a “blind” pouch. In this case, intestines are placed instead of the uterus in the blind pouch created due to hysterectomy (Harvard Women’s Health Watch, 2009). Abdominal hysterectomy is performed when the woman has acquired an enlarged uterus and cancer has been diagnosed or suspected. This procedure takes a vertical incision, about 4” to 6”, along the pubic section and the navel (Harvard Women’s Health Watch, 2009). With respect to morbidity and mortality, research found complications in 44 percent for abdominal and 27.3 percent for vaginal hysterectomies. A Cochrane study found fewer infections and rapid recovery attributed to vaginal and laparoscopic hysterectomies than abdominal hysterectomy (Gupta & Manyonda, 2014).

Techniques and Types of Hysterectomies
Figure 1 Types of hysterectomy: Hysterectomy (uterus only); Total hysterectomy (includes cervix); Total hysterectomy with bilateral salpingo-oophorectomy. SOURCE: Harvard Women’s Health Watch (2004).

Hysterectomy is most necessary when pain cannot be controlled due primarily to fibroids, or pressure and severe bleeding. It can be applied to postmenopausal women who might have malignant tumors and for symptoms of endometriosis which cause pelvic pain, pain during intercourse, and when there is extreme bleeding (Harvard Women’s Health Watch, 2006). Hysterectomy is effective treatment for “menometrorrhagia, leiomyoma, uterine prolapsed, adenomyosis, and postmenopausal bleeding” (Altman, Granath, Cnattingius, & Falconer, 2007, p. 1494). Women with no history of ovarian disease still have their ovaries and fallopian tubes left in place and even if they experience lapses of menstrual periods the ovaries will continue to produce hormones. However, when they undergo hysterectomies, they will occasionally cease from producing estrogen and experience the menopausal stage (Harvard Women’s Health Watch, 2009).

Abdominal hysterectomy.
Figure 2 Abdominal hysterectomy. SOURCE: Editorial staff and contributors (cited in Consumer Health Complete, 2014).
Vaginal hysterectomy.
Figure 3. Vaginal hysterectomy. SOURCE: Editorial staff and contributors (Consumer Health Complete, 2014).

Complications in Hysterectomy

Hysterectomy can lead to psychological or mental problems but some studies have found that hysterectomy provided comfort to women and improved their quality of life. However, women should seek other options before undergoing hysterectomy (Harvard Women’s Health Watch, 2006). The doctor and the patient should have substantial discussion before proceeding and the doctor must observe the highest ethical standards of medical practice.

There are valid medical reasons for hysterectomy but there are as many valid reasons for not performing it, which means there are other options rather than immediately subjecting under the knife the woman’s reproductive region (Gimbel et al., 2003). Epidemiological studies showed that approximately 90 percent of hysterectomies were done for only benign surgical reasons (Darwish et al., 2014). Women who undergo this surgical procedure must be informed of the reasons why it has to be done, how it should be done, including other medical options and complications in later life. Patients have to think of it and give their consent only on life-threatening conditions (Harvard Women’s Health Watch, 2001).

Due to the results of the various studies, the medical profession has raised concerns over the long-term effects of hysterectomy. For example, there have been reported six complications for every 10,000 surgeries performed in the United States (Ruuskanen, Hippelainen, Sipola, & Manninen, 2010). Additionally, studies have found that women who had bilateral oophorectomy had a 17 percent risk of having heart disease and a 28 percent risk of succumbing to death due to complications. Lung cancer was also one of the complications (Harvard Women’s Health Watch, 2009). Moreover, “hysterectomy with oophorectomy has been shown to accelerate menopause by 3-4 years,” which is caused by the disturbance of blood supply in the ovaries and “can have a deleterious effect on cognitive functions” (Phung et al., 2010, p. 44). Some studies also found that women who had undergone premenopausal bilateral oophorectomy showed signs of reduced cognitive functions, but those taking hormone replacement therapy (HRT) reported improved cognitive functions. The reported dementia as a result of hysterectomy is still unexplored, but a longitudinal study of homozygous twins who had undergone hysterectomies showed symptoms of Alzheimer disease (Phung et al., 2010). Brown, Sawaya, Thom and Grady (2009) reported six deaths in 10,000 hysterectomies.

Some studies reported major complication in urinary incontinence (loss of control in urination) and bowel dysfunction which occur in old age and affect women’s quality of life. However, the study of Forsgreen and Altman (2013) on a few randomized clinical trials focusing on the relation of hysterectomy and urinary incontinence provided inconclusive evidence. This is shown in Table 1.

Table 1. Randomized clinical trials on relation of hysterectomy and urinary incontinence. SOURCE: Forsgreen and Altman (2013).
Study, country Participants Duration of Urinary incontinence
Year follow-up symptoms
(years)
Thakar, UK 279 1 Fewer symptoms in both groups
(2002)
Gimbel, Denmark 319 1 Fewer symptoms after total abdominal
(2003) hysterectomy
Learman, USA 135 2 Fewer symptoms in both groups
(2003)

Randomized clinical trials, shown in table 1, indicated that the studies had little evidence to offer because of the few cohort studies conducted. Despite this few evidence of cohort studies, Forsgreen and Altman (2013) still concluded that urinary incontinence and bowel dysfunction were complications for hysterectomies when women reached old age. Brown et al. (2009) supported this finding when they researched on urinary incontinence through Medline articles, using search words, and found that women who had hysterectomy were 40 percent higher in acquiring urinary incontinence at later life than women who had not undergone hysterectomy (Brown et al., 2009). Other complications included occasional fever, hemorrhage, and other life-threatening events (Brown et al., 2009).

Pelvic floor dysfunction is a common problem of women who are of the menopausal stage. Uterine problems can greatly affect women’s social lives, especially in this age of globalization where women have vast roles in society. Hysterectomy can relieve symptoms that have interfered in their daily activities. In the study by Kinnick and Leners (2005) wherein 40 percent of the participants had both ovaries removed, the hysterectomy experience of participants actually decreased their degree of depression. Moreover, all the participants had “a very positive perception of their social support network both pre and post operatively” and the “quality of life experienced by the sample studied increased significantly post-hysterectomy” (Kinnick & Lenners, 2005, p. 141). Physical complications in hysterectomy include edema and swelling in both legs. Long-term physical effects include numbness, tingling, and limited movement of the legs (Hawighorst-Knapstein et al., 2004).

Another factor that affects women undergoing hysterectomies is inequities. Studies have found evidence of inequities for women which need to be addressed by healthcare professionals for a corresponding intervention. The team should determine the psychosocial drawbacks of hysterectomies and meet the psychological needs of women (Guler & Taskin, 2001).

There are cases that hysterectomy is necessary, such as the occurrence of postpartum hemorrhage (PPH), which is related to birth events threatening a mother’s life that affects her adjustment to motherhood (Beck 2004 as cited in Elmir, Schmied, Wilkes, & Jackson, 2012). Severe PPH is described as blood loss of “equal to or greater than 1,000 ml occurring immediately following birth up until weeks postpartum” (Department of Health New South Wales [NSW], 2005 as cited in Elmir et al., 2012, p. 1120). There are cases that PPH needs emergency hysterectomy to control the bleeding (Haynes et al., 2004 as cited in Elmir et al., 2012). PPH and subsequent hysterectomy are two difficult situations that a mother should be able to adjust to after giving birth (Haynes, Hodgson, Anderson, & Turnbull, 1977).

Elmir et al. (2012) conducted a study on perspectives of early mothering by describing their adjustment and recovery from an emergency hysterectomy after a severe PPH. During the recovery period, the mother may be separated from her baby, as she has to be admitted to the Intensive Care Unit (ICU) for observation and careful recovery (Fenwick et al., 2009 as cited in Elmir et al., 2012). During this time, the mother may experience guilt feelings, shame and failure. In Australia, the incidence of women admitted to ICU after birth is 1.84 to 2.6 percent of all pregnant women (Pollock, 2006 as cited in Elmir et al., p. 1120). UK has 0.9 percent of pregnant or postnatal women admitted to ICU (Elmir et al., p. 1120).

On the relation of hysterectomy and breast cancer rate, the study by Woolcott et al. (2009, p. 544) found that there was no “increased nor decreased risk of breast cancer in relation to simple hysterectomy status”. However, the researchers found that risk factors for hysterectomy were also common risk factors for breast cancer. This meant the conditions were similar for both illnesses but there was no relation between hysterectomy and breast cancer (Brett &Madans, 2005).

An analysis of hysterectomy performed for benign disease was conducted at the Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Campus Kiel, Germany, in which the data were taken from hospital records. The causes for surgery included “fibroids, abnormal uterine bleeding, adenomyotic formations, endometriosis, and precancerous lesions of the uterus or the cervix” (Schollmeyer, et al., 2014, p. 45). The techniques used in the various operations included vaginal hysterectomy, abdominal hysterectomy, TLH, LSH, and laparoscopically-assisted vaginal hysterectomy (LAVH). There were 766 patients who qualified for the criteria of the study. The common cause for hysterectomy was uterine myoma, which accounted for 58.6 percent of the study. Vaginal hysterectomy was the common technique used for uterine prolapsed. In the study period, the researchers found no mortalities for hysterectomy for benign reasons but there were 52 (5.5 percent) cases which had complications out of the total 953 operations. For the period 2007 to 2010, the numbers of abdominal hysterectomy and vaginal hysterectomy decreased due to the increase of laparoscopic hysterectomy (LH) and total laparoscopic hysterectomy (TLH).

Figure 2.Increased use of different types of hysterectomy from 2002 to 2010 (AH – abdominal hysterectomy; LAVH – laparoscopically assisted vaginal hysterectomy; LSH – laparoscopic supracervical hysterectomy; TLH – total laparoscopic hysterectomy; VH – vaginal hysterectomy)
Figure 2. Increased use of different types of hysterectomy from 2002 to 2010 (AH – abdominal hysterectomy; LAVH – laparoscopically assisted vaginal hysterectomy; LSH – laparoscopic supracervical hysterectomy; TLH – total laparoscopic hysterectomy; VH – vaginal hysterectomy). SOURCE: Schollmeyer et al. (2014).

Some studies found symptoms of psychological co-morbidity due to hysterectomy which can result into negative feelings about body image, sexual orientation, youth, energy and physical activities, and “loss of child-bearing capacity” (Darwish et al., 2014, p. 6). However, in conducting a meta-analysis of the different studies and articles on hysterectomy, Darwish et al. (2014, p. 14) found that hysterectomy performed for benign gynecological conditions was “not adversely associated with depression or anxiety outcomes.” Moreover, long-term studies suggested that women returned to their physical and psychological functioning after hysterectomy. Darwish et al.’s (2014) study further found that hysterectomy, no matter what type and technique used, had improved the quality of life and psychological outcome of women. There was a reduction in the symptoms of depression and depression scores compared to the preoperative indications. This suggests that women usually felt comfort after the non-malignant indications were removed due to hysterectomy. Sexual pleasure, arousal and desire improved after hysterectomy, regardless of the surgical technique used (Darwish et al., 2014).

Impact of Hysterectomy on Women’s Lives

In other cases, hysterectomy creates psychological problems such as depression and low self-esteem, and negative outcome on patients’ social lives (Cohen, Hollingsworth, & Rubin, 1989; Bachman, 1990; Griffith-Kenny; Hugnagel, 1989 as cited in Kinnick&Leners, 2005). Fleming (2003 as cited in Elmir et al., 2011) indicated that women feel intense pain right after hysterectomy. In a similar case, Linenberger and Cohen (2004 as cited in Elmir et al., 2011) studied 65 women, who had a mean age of 42 years, experiencing abdominal or vaginal hysterectomies. The researchers found that hysterectomies limited their physical activities while others felt the experience was worse than a caesarian operation. A caesarean operation accompanied with hysterectomy requires time to recover, as this may result into emotional, physical and psychological stresses (Kinnick&Leners, 1995; Fleming, 2003; Flory et al., 2005 as cited in Elmir et al., 2011).

Hysterectomy without ovary removal is a different case. Bachman (1990 as cited in Kinnick & Leners, 2005) argued that hysterectomy should not greatly affect women if the ovaries are not removed. However, quality of life should be considered when determining the effects of illness (Goodinson & Singleton, 1989 as cited in Kinnick & Leners, 2005). Quality of life is linked with the individual’s sense of comfort and happiness in life. Studies in Taiwan and Turkey have found that women regard “the uterus as the symbol of femininity, sexuality, fertility, and maternity, and the loss of this organ is identified as the loss of womanhood because giving birth to a child is an important function for many women” (Pinar, Okdem, Dogan, Buyukgonenc, &Ayhan, 2012, p. E99). In the study on hysterectomized women, Pinar et al. (2012, p. E103) found that “hysterectomy had significant negative effects on patients’ body images, self-esteem, and marital adjustments.”

Some other studies showed that hysterectomies improved women’s quality of life. To answer the various concerns about the overuse of hysterectomy, scholars from the University of California at San Francisco conducted a study on hysterectomy and other treatment options and their impact on women’s quality of life. The study employed 63 participants, aged 30 to 50, who were suffering from excessive bleeding for four years. The women took synthetic progesterone treatment but this was unsuccessful. The researchers recommended hysterectomy to a group of participants and some to hormonal medication or birth control pills. The researchers asked the participants of their opinion about quality of life, their physical and mental conditions, and their feeling after hysterectomy. After a period of six months, the participants who underwent hysterectomies reported reduced abnormal bleeding, and had improved sleep and quality of life, including over-all health and well-being. Seventeen of the 32 members of the medication group opted to have hysterectomy and also reported improved well-being. But the participants who did not undergo hysterectomy also reported improvement in their quality of life (Harvard Women’s Health Watch, 2004).

Additionally, in a 2000 survey of hysterectomized women, the researchers found that respondent women reported improved sexual functioning (Obstetrics and Gynecology, 2000 as cited in Harvard Women’s Health Watch, 2007). A randomized survey in 2007 by “BJOG: An International Journal of Obstetrics and Gynecology” supported this finding, wherein respondents who had hysterectomy reported enhanced sexual functioning than they had before they underwent hysterectomy (Harvard Women’s Health Watch, 2007). In a report by the Maine Women’s Health Study, many women indicated that they were satisfied with the result of hysterectomy. In a study on women aged 25 to 50 who had either hysterectomy or noninvasive treatments for benign tumors, fibroids, abnormal bleeding, and pain in the pelvic region, Dr. Karen Carlson of the Women’s Health Unit at Massachusetts General Hospital in Boston found positive perceptions of hysterectomy. The respondents reported that hysterectomy relieved their gynecologic problems and that their physical and mental health improved. A small percentage of the population indicated that they lost libido and had little sex enjoyment (Harvard Women’s Health Watch, 1994).

Women and Informed Consent Law

It is noteworthy to provide some actual cases of hysterectomy in this section to define the impact of this medical practice on women’s lives. Nora Coffey (2013) underwent surgery to get rid of a benign cyst but later found out that the doctor who operated her also removed the uterus and ovaries. It was a traumatic experience for this woman that led her to some unexplored activities as a woman and as a health activist later on. Coffey then founded a not-for-profit foundation known as the “Hysterectomy Educational Resources and Services Foundation” (HERS) to provide valuable information for women who might experience non-life threatening medical situations and the benefits of an informed consent law before they undergo hysterectomy (Coffey, 2013).

Another case involved a happily married woman who was rushed to a hospital for emergency appendectomy. During the operation, the surgeon found severe endometriosis. A gynecologist was asked to give an opinion and she concluded that the best option was to remove the fallopian tubes and the ovaries. It was found that the patient had a bilateral ovarian cystectomy for endometriosis in 1979 but was not informed that it would create a serious problem in the future. The patient was completely depressed to learn that she had lost her reproductive organs. She went into a depression and her marriage crumbled. In 1992, her case was reopened upon the woman’s request, and the review stated that the gynecologist did not have a chance to talk to the patient. The endometriosis was so severe that the patient would not have a chance of natural conception and the cysts should be removed. The review also concluded that new consent forms should have a space in which patients can designate procedures which they do not wish to be done. According to Brahams (2009), women who awoke finding that they had lost their womb and reproductive organs considered their situation as if they were raped or went under “castration”. Brahams (2009, p. 361) recommended that there should be “a delayed procedure with renewed consent, albeit with the risks and inconveniences attached to a second operation.” In other words, the patient should have time to consult and think about her situation and all information should be provided.

The Sarah Lee Brown case

In 1981, a case involving Sarah Lee Brown and Dr. John Mladineo became the subject of a legal battle over medical malpractice. Instead of only the tumor to be removed, Dr. Mladineo made a complete hysterectomy on Ms. Brown. After a week of discharge from the hospital, Brown complained of excreting bodily waste by way of her vagina. When the doctor was informed of Brown’s complaint, he advised the patient to take a peculiar treatment – drink some vinegar. Brown was admitted to the same hospital where Dr. Helen Barnes treated her for rectovaginal fistula, which was caused when Dr. Mladineo performed the surgery and accidentally created a canal in the rectum to the vagina (Justia US Law, 1987). This case should not have happened if there was an adequate informed consent law regulating surgeons before performing hysterectomy.

Comprehensive Informed Consent Law

During the days of slavery in America, black women were subjected to sterilization because they were deemed not to provide offspring. This was known as the “Mississippi Appendectomy”. In the 1950s, black women were provided with contraceptives so that the black population would not grow (University of Maryland, n.d.).

It is a different environment today. A woman’s reproductive decisions are protected under the Fourteenth Amendment of the U.S. Constitution. Court decisions support the principle that reproduction is part of the “very core of human identity” and “reproductive choices are deemed protected rights belonging to the realms of individuality, privacy, and autonomy,” which should not be bypassed by any government agency or regulation (Laufer-Ukeles, 2011, p. 569). Although Supreme Court jurisprudence states that the right to reproduce includes “the context of contraception, abortion, and the right not to undergo sterilization” (Skinner v. Oklahoma, 316 U.S. 535, 541, 1942 as cited in Laufer-Ukeles, 2011, p. 569), law scholars and practitioners contend that these rights should extend to the areas of “procreation and birth decision making as well” (Amy Cohen, 1992 as cited in Laufer-Ukeles, 2011, p. 569). Birth decision making and procreation are personal choices that are supported by public policy, husbands and wives’ testimonies on the meaning of such choices and the social consequences of those choices (May, 2004).

However, Laufer-Ukeles (2011) argued that reproductive choices are usually made with the influence of a doctor in the hospital, supported by government funding and legislative mistake. The state regulates and controls reproductive choice based on its policy of promoting “citizen health and societal values,” despite the constitutional provision that protects such choices (Laufer-Ukeles, 2011, p. 569). In a country which has a comprehensive informed consent law, a woman with problems in the reproductive organs is given options to choose. The doctor must explain the various reasons, but the woman must have the final choice. Other states have passed their version of the law. North Carolina enacted the “Woman’s Right to Know Act” which provides that women should be provided necessary information before they decide to have an abortion (Stam, 2012, p. 4).

The traditional practice of hospitals is that when a patient is scheduled for surgery, she is made to sign a consent form. The form contains provisions where the surgeon is authorized to perform further surgery where the surgeon thinks necessary. In this case, there should be an open discussion with patient regarding those options that will come out during the surgery. The form should not be over-all consent. The patient can seek redress by asking police assistance or directly go to court (Brahams, 2009).

Alternatives to Hysterectomy

Complications in hysterectomy force some in the medical profession to perform alternative treatment and one of these is uterine artery embolization (UAE). According to a study, UAE provides symptomatic relief compared to hysterectomy (Ruuskanen, 2010). There have been positive findings of patient satisfaction for UAE, like shorter time of hospitalization, but the patient has to go through surgical intervention after a few years (Scutiero et al., 2013). UAE is also effective treatment for myoma (Dueholm, Langfeldt, Mafi, Eriksen, &Marinovskij, 2014).

There are other alternatives to hysterectomy provided by the medical profession. For menorrhagia, women are now aware of the other treatment options. Endometrial ablation, which targets the lining of the uterus, is simpler to perform with lesser complications than hysterectomy (Greenberg, 1983). The National Heavy Menstrual Bleeding Audit of the Royal College of Obstetricians and Gynecologists and the National Institute for Health and Clinical Excellence (NICE) have advised that women experiencing extreme menstrual bleeding should undergo “second generation ablative procedures” (Higham& Shaw, 1990, p. 211). NICE reported that ablation as alternative to hysterectomy can improve women’s quality of life. If it still failed, then the patient should be advised to undergo hysterectomy (Gupta &Manyonda, 2014).

A technical innovation that is gaining popularity is the use of uterine manipulator (UM) which is under the classification of minimally invasive hysterectomy (MIH). The doctor moves the uterus by way of the vagina, improving exposure in the pelvis and increasing “the distance between the ureter and the operative field” (Zhang et al., 2014, p. 212). One problem with MIH is when the UM disseminates cancer cells, although this is still a debatable one because of the lack of empirical studies regarding this issue. The surgeon inserts the manipulator which increases intrauterine pressure when the balloon is inflated. This can enhance lymph vascular space invasion (LVSI) or enhance the passage of malignant cells through the fallopian tubes into the peritoneal cavity. Another problem with the UM is that it can disaggregate tumor cells (Zhang et al., 2014).

An alternative to hysterectomy for women with excessive menstrual bleeding (that is not due to cancer, fibroids, or endometriosis) is “the procedure called balloon ablation” which destroys the endometrium, or uterine lining, but does not involve uterus removal. The principle reflects that of the balloon angioplasty procedure, which also uses a “balloon” to open blocked coronary arteries. In balloon ablation, a balloon-tipped catheter is inserted into the vagina, passing through the cervix, and finally into the uterus. A sterile solution is attached to the balloon so that it coincides with the shape of the uterus. Something is placed in the balloon to heat the fluid to 190 degrees Fahrenheit temperature. The heating process lasts for 8 minutes. The purpose of the heating process is to destroy the endometrial tissue that touches the balloon. The final stage consists of deflating the balloon, draining the fluid through the catheter, and removal of the catheter (Harvard Women’s Health Watch, 1996).

Reducing Variations in Surgery

Doctors can reduce variations in surgeries for ethical and economic reasons. Reducing variation can help a lot of patients and reduce mortality and unwarranted use of resources. Patients can have other choices if the surgery can offer no benefits. McCulloch and colleagues (2013) suggest that patient autonomy can reduce variation. However, reducing variations should be assessed by experts in the health profession who must have a broad and clear interpretation of the facts in a particular case. The doctors involved should conduct further investigation if a proposed hysterectomy case is clear with the patient or not. There should be good evidence to provide a surgical intervention that is effective for such a disease (McCulloch et al., 2013).

Causes of variation include “the need or value, the delivery system factors, local cultural beliefs (both public and professional), and the availability of robust, relevant, and casemix-adjusted data. The decision pathway to surgery can be modified in numerous and complex ways” (McCulloch et al., 2013, p. 1131). Surgery today is confronted with “the culmination of a very low death rate, very low complication rate, and softening indications for operation” (Polk, 2006, p. 1133).

Polk (2006) suggests that signs for operation are difficult to discern in surgical guidelines and many published material only point to patient care after the decision for operation has been made. Indications for hysterectomy have been much abused because these were not clear, which means hysterectomies were conducted without substantial reasons or causes why they should be performed (Carlson, Nichols, & Schiff, 1993).

Evidence about the benefits and risks of surgery is significant in the decision to reduce variations but it is not a decisive one. Variation for surgery can be provided if there is no treatment benefit or if there is no identification of best treatment. Some new techniques of surgical practice have been introduced but these are incomplete and slowly implemented, which means there is still lack of evidence for its success (McCulloch et al., 2013).

A Cochrane study on the effects of clinical decision making of passive distribution of review evidence showed that appropriate reduction in surgery rates can be accomplished with the distribution of a bulletin. Educational measures distributed to surgeons doing operations resulted in 9 percent fall in the operation rate. Additionally, shared decision making, which aims to give patients balanced information and a friendly atmosphere to give them the chance to choose the right treatment that fits their values and beliefs, is an ethical priority for the doctor and can reduce unwanted variation in surgery rates (McCulloch et al., 2013).

The Principle of Informed Consent

The principle of informed consent states that doctors and other health professionals should provide information on health risks and treatment options and get their consent to proposed medical procedures from their patients (Manian, 2009 as cited in Laufer-Ukeles, 2011). Women should be legally and humanely advised before undergoing hysterectomy. Without a consent law, it is possible that some physicians will not brief their patients about the complications. Passage of a law means reducing threats or health risks and patients are protected from medical malpractice. A comprehensive informed consent law provides that doctors inform women of the parameters and consequences before they give their consent to undergo hysterectomy. Informed consent is provided to enhance “patient autonomy” (Laufer-Ukeles, 2011).

Mississippi women give their consent for surgical procedure without an informed consent law, which challenges their health and rights as women. With informed consent law, the doctor is mandated to provide information about all treatment options and effects of hysterectomy to a woman who is about to undergo hysterectomy. The doctor should provide all the information and the patient should be the last to decide with the assistance of the doctor. Laufer-Ukeles (2011) suggests that there should be a consensus between the doctor and the patient undergoing hysterectomy. With an informed consent law, the doctor is obliged to discuss with the patient on whether hysterectomy should be performed (Broder, Kanouse, Mittman, & Berstein, 2000).

Informed consent is a legal term that lays down the manner in which physicians or surgeons conduct treatment or surgeries on their patients. In the medical profession, physicians are obliged “to explain the nature of proposed medical treatment, its prognosis for treating the medical problem, its dangers, and alternatives to the proposed treatment” (Owens, 2009, p. 34). The law provides for fines and other punishments if physicians diverge from what they are supposed to observe under the law and ethical principles, based on people’s treasured worth of “autonomy” (Berg, Appelbaum, Lidz, & Parker, 2009). When a patient and surgeon enter into an agreement, they are governed with certain rules and ethical practice (Maclean, 2009). This is one ground why such a law should be passed in Mississippi.

The principles of medical law provide that autonomy and consent are related. The focus of informed consent is that the doctor should provide all information as this is important to the patient’s decision whether to have a hysterectomy or not (Maclean, 2009). Autonomy focuses on guiding where one is going, deciding where to go and in what activities to engage (May, 2002 as cited in Taylor, 2004). Beauchamp and Childress (2008) also supported the autonomy principle in the context of informed consent. Informed consent enhances the patient’s “freewill” (Taylor, 2004, p. 383). Autonomy also connotes treating an individual with informed consent (Varelius, 2007) as opposed to James Taylor’s contention that when a patient is being treated, the well-being of that person is the primary concern (Maclean, 2009).

Autonomy means the patient dictates her life’s direction. For a patient to be autonomous, specifically in her decision to undergo a medical treatment, the doctor should not stop her decision, or control her decision by selecting information about medical options. Otherwise, the doctor would compromise the woman’s decision regarding her medical treatment. All information about other treatment options should be given to her. Healthcare professionals can refrain from taking over the patient’s autonomy by providing them with all information about the alternative courses of treatment that are at their disposal, including the advantages and disadvantages of those options (Taylor, 2004). Some medical scholars and researchers have recommended reducing variation in surgical procedures, which has ethical and economic effects on surgery rates. Patient autonomy can be elevated and she can choose to avoid it if there are no benefits to be derived from surgery (McCulloch et al., 2013).

Although attacked on both sides, the principle of informed consent has impacted the medical profession (Schneider, 2005 as cited in Laufer-Ukeles, 2011). The concept of providing necessary information and acquiring consent from the woman to be placed under the knife has become a benchmark for change from the traditional protectionist and patriarchal method of treatment and a benchmark for yearning of enhancing women’s rights. There may be shortcomings to this present trend but patients’ rights, hospital ethics, the need to provide appropriate medical information to patients, and the need to acquire patient’s consent are now ordinary procedures in medical institutions, hospitals, clinics, and doctors’ dealings with their patients (Laufer-Ukeles, 2011).

In North America, some hysterectomies were performed by doctors even if they were not necessary. Investigations were conducted in the United States and Canada which found that there were unwarranted hysterectomies performed. The medical profession is not united on this medical procedure regarding the reasons for hysterectomies in women (Roos, 2007).

As mentioned, there are minor and serious complications in hysterectomy. The Hippocratic code on medical ethics states that “the physician will use treatment to help the sick according to his ability and judgment, but never with the view to injury and wrongdoing” (Hippocratic Corpus, 1923 as cited in Bhutta, 2004, p. 771). Furthermore, if the patient can have a choice of another method of therapy, it is possible that the mode of therapy is less expensive than surgery (Taylor, 2004). The doctor has a big role to play in the woman’s decision, but the doctor can also influence the decision. This, however, depends on the provisions of the informed consent law.

Proponents of women’s autonomy argue that the woman has individual right, more valuable than the right of the fetus. They criticize “the paternalistic control of reproductive choices by the state or doctors and seek freedom from such influences in order to resolve women’s compromised autonomy” (Laufer-Ukeles, 2011, p. 571). There are others who argue that women’s autonomy is weakened because of “discrimination and power differentials” (Laufer-Ukeles, 2011, p. 572). With the principle of informed consent, any doctor who operates on a woman and removes something from the reproductive organ without the patient’s consent, commits an offense like “battery or assault” (Laufer-Ukeles, 2011, p. 575). Patients’ consent is not the only thing necessary, rather, adequate information that can help in the patient’s promulgation of a logical decision should be provided by the doctor. Patients can also refuse any treatment indorsed by the doctor and the doctor can be unethical and may violate the law if he/she refused to provide information regarding the patient’s condition, including “the risks, alternatives, and potential side effects” as a result of the treatment (Laufer-Ukeles, 2011, p. 575).

Concerned organizations have provided guidelines which include a case-to-case risk assessment based largely on the woman’s family history. Perera et al. (2013) conducted a study on women who underwent hysterectomy for the period from 2000 to 2010 and patients who underwent bilateral oophorectomy. The study identified 752,045 women who underwent hysterectomy wherein 403,073 patients had ovarian conservation while 348,972 underwent bilateral oophorectomy. The number of ovary removal has been controlled, particularly on women ages 45 to 49This is shown in figure 3.

Ovarian conservation by year stratified by age.
Figure 3. Ovarian conservation by year stratified by age. SOURCE: Perera (2013).

The study of Perera et al. (2013, p. 721) suggests that ovarian conservation has been increasing. Procedural factors influenced this trend, such as “the indication for surgery and route of hysterectomy” which influenced the most for retaining the ovaries. Hospital characteristics influenced about 10 percent in the decision to conserve the ovaries, while 5 percent and 3 percent were attributed to patient decisions and physician characteristics, respectively (Perera et al., 2013). The researchers noted the variation and group the participants according to age and for those who underwent vaginal hysterectomy or not. There were about 2,000 to 10,578 hospitals that admitted and subjected 68,022 women of this latter grouping. The percentage of ovarian conservation registered at 37.2 percent. The findings of the study suggested that the rate of ovarian conservation during hysterectomy for benign reasons for young women aged 50 years increased (Perera et al., 2013). Hospitals across the United States have chosen to tread along the path of ethical practice by performing hysterectomy and bilateral oophorectomy only on extreme cases. The trend for ovarian conservation is influenced by data collected by hospitals that “oophorectomy may increase the long-term risk of coronary heart disease and possibly mortality” (Rocca et al., 2006; Parker et al., 2009; Parker et al., 2005; Berek et al., 2010 as cited in Perera et al., 2013, p. 725).

Gender Identity

A woman’s reproductive system is associated with gender identity. When this is removed by surgical means, the woman loses “the deepest sense of what one is” (Elson, 2002, p. 37). Medical sociologists argue that medical treatments like hysterectomies can affect people’s lives. When a woman undergoes hysterectomy, she loses one part of her identity as a woman and that is menstruation. Medical sociologists contend that “menstruation and female gender identity are strongly associated” (Elson, 2002, p. 38). Martin (1992 as cited in Elson, 2002) found in a study that respondents described menstruation as something that defines a woman, and that it was like “a mark of womanhood”. Menstruation makes women different from men and they just would not like to give it up easily through hysterectomy. Menstrual periods provide “a symbolic and material bond between women” (McClintock, 1971 as cited in Elson, 2002, p. 38). Hysterectomy marks the end of a woman’s menstruation which disturbs gender identity as this is closely related with womanhood (Angier, 1999; Martin, 1992 as cited in Elson, 2002).

Quality of Life (QoL)

The process of healing must be in several stages. Although painful as it may be, a woman who undergoes hysterectomy becomes a new individual. Healing stages must be experienced with care and positive attitude. The loss of one part must lead to the recovery of new life’s horizons. Long (2002) indicated that women who have undergone hysterectomy should find “developing a new way of looking at the world, a new level of consciousness” (Jung, 1958 as cited in Long, 2002, p. 536).

Nursing care should be planned adequately to correspond to the various stages of the healing process. Specific nursing care should make the patient move from the stage where she was dependent through a stage where she becomes conscious, self-actualizing, and independent. The first stage should involve the patient to come out of isolation. Breaking free from hiding and numbness and accepting the innermost pains are significant movements that should be followed. Second, the numbness must be resolved and transformed into feeling. According to Kora and Sato (1958 as cited in Long, 2002, p. 537), suffering is “a universal fact of human condition” and acceptance of suffering is the best way to counter it. Visits from a mental health nurse or a professional person who can provide meaningful counseling is essential. The next stage is releasing or emptying, which involves “embracing fear and womanhood” (Long, 2002, p. 537). Fox (1983 as cited in Long, 2002) provided the process of emptying in four vital steps:

  • The patient must take hold of the pain like a pack of sticks to build a fire.
  • The sticks have to be held in an embrace so that the person can move across the room to the fireplace.
  • When reaching the fireplace, the individual can release the sticks and let them go.
  • After all the steps, the individual feels warmed and happy from the sticks she has thrown out to the fire.

According to Long (2002), the individual who has undergone hysterectomy must embrace womanhood once again, after she has suffered from the medical event. Long (2002, p. 542) advised that, “Suffering softened me and allowed me to feel more compassion and love towards others.” A woman who chooses to undergo hysterectomy must endure the pain because this can lead to an improved quality of life (QoL). QoL is multidisciplinary but its definition is not universal as it can be seen from different perspectives. There are also several notions and concepts which are influenced by culture. The World Health Organization classifies QoL into six broad areas: “physical, psychological, level of independence, social relationship, environment and spirituality, religion, or personal belies” (Bayram & Beji, 2010, p. 4). Each of these areas affects all the others while QoL covers the entirety and wholeness. The WHO definition highlights life’s goals, expectations, aims and anxieties of individuals as they go on and meet life’s sufferings. “Health-related quality of life” (HRQL) encompasses the person’s entire well-being. According to international experts, HRQL includes the physical, social, and emotional areas of a person’s functions, including awareness of “overall quality of life or general life satisfaction” (Bayram & Beji, 2010, p. 4).

Positive and negative effects can be seen on women who undergo hysterectomy. With the loss of fertility, the woman may become anxious and afraid of the many personal issues surrounding her life and her relationships with the people around her, particularly her husband. Women complained of difficulties in uterine problems, to include physical and menstrual pain, emotional and sexual dysfunctions and the decline in general health.

Conclusion

This literature survey has explored the advantages and disadvantages in hysterectomy. The empirical studies provided the pros and cons and hysterectomies and the reasons why doctors recommend surgeries. The surgeon should provide the necessary information for the woman to choose what best suits their health. Like any other medical activity or event, doctors have varying views. There were patients who reported of improved life while others had negative feelings about hysterectomy. In other words, the subject needs more empirical studies to substantiate what is in the literature. The presence of informed consent law can also affect the outcomes.

The Health Belief Model

This study will use a theoretical framework known as the Health Belief Model (HBM) to determine problems of behavior. Researchers use HBM to understand and predict how patients apply health prevention and services. HBM begins with a hypothesis that actions pertaining to health are influenced by factors like: the presence of adequate motivation to make problems of health significant; the idea that a person is at risk to a health issue or as a consequence of that health problem, or there is the perception of a health threat; and the belief that observing a doctor’s or a health worker’s recommendation would reduce the health issue at lesser costs.

Authors argue that HBM is linked with social cognitive theory (SCT) (Rosenstock, Strecher, & Becker, 1988). Rosenstock (1974 as cited in King, Singh, Bernard, Merianos, & Vidourek, 2012, p. 194) further expounds on the concept of HBM elements, such as “perceived benefits, perceived barriers, and cues to action.” Individuals exhibit certain behaviors when they feel that: 1) benefits are derived in exhibiting the behavior, 2) the benefits are greater than the barriers in displaying such behavior, and 3) there are clues reminding them to display such behavior (Rosenstock, 1974 as cited in King et al., 2012). This concept was later modified and combined with Howard’s (1989) model: individuals need a stimulant to enhance their decision-making process, or they need to be motivated with what is known as environmental cue (Howard, 1989 as cited in Risker, 1996). The combination of Howard’s (1989) model and HBM provides explanation of patient behavior relative to the subject of health services. The model further explores that when individuals look for information about their health, the motivation relies on how confident they are in understanding and providing excellent choice with regards their health. Self-belief and experience of an exact choice are relevant when the individual seeks information about availability of health service (Risker, 1996).

Rosenstock (1974 as cited in King et al.) explained that for individuals to take action to avoid sickness, they have to believe that (a) they are vulnerable to the disease; (b) the disease can inflict a severe impact on some part of their lives; (c) certain behaviors can reduce the severity of the disease whenever the disease inflicts upon them; and (d) these behaviors can not be hindered by aspects like expenses, pain, and humiliation, or the perceived barriers. HBM has a predictive ability and we can expand this to include the concept of self-efficacy which is perception or belief in how competent an individual in possessing certain behavior (Bandura, 1977 as cited in Lin, Simoni, & Zemon, 2005).

HBM constructs assert that individuals make decisions based on their beliefs and perceptions. The individuals’ actions relate to surgeries, preventive care, and other form of treatment (Bellamy, 2004). HBM can provide explanation on theories regarding the experiences and treatment responses/reactions of Mississippi women who have undergone or will undergo hysterectomies. Some questions that need responses in this instance are: Does the absence of informed consent law affect the Mississippi women’s decision to undergo hysterectomies? Are the women well-informed about the causes and complications of hysterectomy? What are the advantages and disadvantages of having informed consent law for Mississippi women?

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Reference

NerdyBro. (2022, July 1). Hysterectomy and Stress-Urinary-Incontinence Surgery. Retrieved from https://nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/

Reference

NerdyBro. (2022, July 1). Hysterectomy and Stress-Urinary-Incontinence Surgery. https://nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/

Work Cited

"Hysterectomy and Stress-Urinary-Incontinence Surgery." NerdyBro, 1 July 2022, nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/.

References

NerdyBro. (2022) 'Hysterectomy and Stress-Urinary-Incontinence Surgery'. 1 July.

References

NerdyBro. 2022. "Hysterectomy and Stress-Urinary-Incontinence Surgery." July 1, 2022. https://nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/.

1. NerdyBro. "Hysterectomy and Stress-Urinary-Incontinence Surgery." July 1, 2022. https://nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/.


Bibliography


NerdyBro. "Hysterectomy and Stress-Urinary-Incontinence Surgery." July 1, 2022. https://nerdybro.com/hysterectomy-and-stress-urinary-incontinence-surgery/.